Activating Autoantibodies to the Beta-1 Adrenergic and M2 Muscarinic Receptors Facilitate Atrial Fibrillation in Patients With Graves' Hyperthyroidism

Objectives We studied activating autoantibodies to β1-adrenergic (AAβ1AR) and M2 muscarinic receptors (AAM2R) in the genesis of atrial fibrillation (AF) in Graves’ hyperthyroidism. Background AF frequently complicates hyperthyroidism. AAβ1AR and AAM2R have been described in some patients with dilated cardiomyopathy and AF. We hypothesized their co-presence would facilitate AF in autoimmune Graves’ hyperthyroidism. Methods IgG purified from 38 patients with Graves’ hyperthyroidism with AF (n=17) or sinus rhythm (n=21) and 10 healthy controls was tested for its effects on isolated canine Purkinje fiber contractility with and without atropine and nadolol. IgG electrophysiologic effects were studied using intracellular recordings from isolated canine pulmonary veins. Potential cross-reactivity of AAβ1AR and AAM2R with stimulating thyrotropin receptor (TSHR) antibodies was evaluated before and after adsorption to CHO cells expressing human TSHRs using flow cytometry and enzyme-linked immunosorbent assays. Results The frequency of AAβ1AR and/or AAM2R differed significantly between patients with AF and sinus rhythm (AAβ1AR = 94% vs. 38%, p<0.001; AAM2R = 88% vs. 19%, p<0.001; and AAβ1AR+AAM2R = 82% vs. 10%, p<0.001). The co-presence of AAβ1AR and AAM2R was the strongest predictor of AF (odds ratio 33.61, 95% CI 1.17 - 964.11, p=0.04). IgG from autoantibody-positive patients induced hyperpolarization, decreased action potential duration, enhanced early afterdepolarization formation and facilitated triggered firing in pulmonary veins by local autonomic nerve stimulation. Imunoadsorption studies demonstrated that AAβ1AR and AAM2R were immunologically distinct from TSHR antibodies. Conclusions AAβ1AR and AAM2R when present in patients with Graves’ hyperthyroidism facilitate development of AF.